Preview
COMPLAINT
in the DISTRICT Court for the County of LAKE in the State of FLORIDA
Case Number:
Date: December 21, 2022
GENERAL INFORMATION
IDCAIDSY
PLAINTIFF
Ms. Tien T Dang
5356 Treasure View Way, Leesburg FL. 34748
DEFENDANT:
Mr. Margo Jenkins
AAA Life Insurance Company
17900 N. Laurel Park Drive, Livonia, MI. 48152
RE: AAA Life Insurance Claim Number: 2100013682
New policy number issued February 26,2020:# 4042532939
Old policy number issued in July 2013: #4022724274
Insured: Mr. Thu Nguyen
Date of Loss: 08/29/2021 Jur{ Tial Deaneef’
DESCRIPTION OF COMPLAINT:
1. Mr. Thu Nguyen applied and got approved for $100,000 of Group Term Life Insurance in 2013 from
AAA in San Jose, California. The insurance number 4022724274 was put into effect and signed by Mr.
Harold W. Huffstetler, Jr. The approval letter stated that “Once in effect, you can renew it through
the age of 79 regardless of any changes in your health.” The monthly premium was $125.62 and
kept unchanged from year 1 to year 10. The policy won’t be expired until 7/11/2045. The premiums
were deducted automatically monthly through our checking account at the Bank of America.
2. At the same time, to counterpart with his decision, I also applied for a term life insurance in San
Jose, California, and got approved for the same amount $100,000. The policy number is 4022724290
and the premium was $$8.40 automatically deducted through the same Bank of America.
3. We moved to Florida in 2018. On 02/26/2020, AAA issued a new 10 years Term life insurance policy
to Mr. Thu Nguyen and the number is 4042532939. The monthly premium was increased from $125.62
to $154.20. What were the reasons behind that AAA replacing a new policy while the 100K amount
and other terms were unchanged? Who was the party, AAA or Mr. Thu Nguyen, who initiated the ®
request? Does AAA still have all the evidence, letter, and/or audio conversation at the time of the policy
replacement?
4. Mr. Thu Nguyen passed away on August 29, 2021, from COVID-19. I submitted the claim with AAA
in September 2021 as the survival benefit. AAA issued claim'# 2100013682.
5. As his wife, I did not recall why Mr. Thu Nguyen requested a new policy. The premiums should be
unchanged after 10 years as stated per the old policy. I did not know-he had a new policy when I
claimed the 100K after his death on August 29, 2021, as part of the survival benefit. In March 2022, I
stopped at one local AAA office in Lady Lake and met ‘with Mr. Alex Hanson, the AAA financial
specialist.He told us the reason the claim was delayed because of the new contract issued less than 2
years from the date issued date Feb 26, 2020. I reviewed my own AAA policy at that time and it was .
the same monthly amount of $8.40. The policy number was unchanged # 4022724290.
6. As part of the claim investigation, AAA concluded that Mr. Thu Nguyen’s No answer to application
question 4 was a misrepresentation. The medical records demonstrated that he was diagnosed with
Hepatitis B prior to the Application date of 02/26/2020. Therefor re AAA exercised its right to deny the
100K coverage. .
7. Does AAA still have the evidence, written and or audio conversation during the new application
process of the answer question 4? The answer No to this question was in both old and new policies. Mr.
Thu Nguyen got treatment from a medical professional after the diagnosis.
8. For question 1 related to heart disorder, high blood pressure, or elevated lipids, the answer is YES for
the old policy-and NO for the new one. The reason for the different answers was that he knew he had
these sicknesses, so he got treated by a member of the medical profession after the diagnosis. He also
turned to a Vegetarian/Vegan diet in 1993 to improve his health and cure these diseases.
Damages WHEREFORE, Plaintiff seeks compensatory damages in the amount of $100,000 as stated
per the term life insurance policy agreement plus all attorney fées and costs incurred by Plaintiff in
connection with this action. Respectfully submitted this 21st day of December 2022.
Name: Tien T Dang, Plaintiff
adeng
_ Company
17900 N. Laurel Park Drive
Livonia; Michigan 48152
Phone: 800-624-1662
May 26, 2022 Fax: 888-223-1509
claimssvc@aaalife.com
Tien Thi Dang
14055 SE 93rd Ter
Summerfield, FL 34491
RE: AAA Life Insurance Claim Number: 2100013682
Contract Number: 4042532939
Insured: Thu T Nguyen
Issue Date: 02/26/2020
Date of Loss: 08/29/2021
Dear Tien Thi Dang,
Thank you for your patience while we reviewed the submitted. information on this claim.
.
Please accept our sincere sympathies on your loss.
We have had an opportunity to review your April 28, 2022 correspondence in conjunction
with the previously reviewed claim documentation. Unfortunately, no additional information
was provided that would cause us to change our April 11, 2022 decision fo rescind and
void the coverage under policy 4042532939.
Briefly, in response to your question regarding why the contract number changed, your:
husband Thu Nguyen replaced his coverage with a 10-year’ Term Life policy with an Issue
Date of February 26, 2020 and a new contract number 4042532939: The new policy, as
you are aware from our April 11, 2022 letter, had a two-year contestability period from the
contract Issue date. Your husband’s death occurred during that two-year period. As the
death occurred within the two years, during the contestable period, there was a.claim
.
investigation.
The claim investigation concluded that Thu Nguyen’s No” answer to.Application Part 2,
question four (4) was a misrepresentation. The medical records demonstrated that Mr.
Nguyen was diagnosed with Hepatitis B prior to the Application date. Mr. Nguyen was
followed by the liver specialist for this disease. The question did not ask about his current
treatment status with the condition but rather
“Have you ever been diagnosed, treated, or consulted a licensed medical
professional for:
4. Diabetes, thyroid disorder, pancreai tic disorder, liver disorder, hepatitis or
kidney disorder?”
As you know, Mr. Thu Nguyen answered “No” to this question.
Page 3 of 3
| hope this fully explains how this determination has been reached. If you have questions
tegarding this mat ter, Please contact our office at 1-800-624-1662, and follow the prompts.
for Claims."
We appreciate the opportunity to respond, and am sorry we are unable to honor the
request for benefits.
Sincerely,
Greg Thomsow
Greg Thomson
Claim Consultant, Claims Department
a ~—
4+7900°N- Laurel Park Dr: Livonia, MI48152-—
Direct: 734-779-2927 | 800-624-1662 Ext. 2927
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NEW POLICY # 4042532939
Policy Schedule Page
Policy Number: 4042532939 Effective Date: 02/41/2020
Owner: THU T NGUYEN Issue Date: 02/26/2020
Insured: THU T NGUYEN Issue State: FL
Issue Age: 69 Gender: Male
Face Amount: | $100,000 Rate Class: STANDARD NON-
NICOTINE
Billing Mode: Monthly EFT Initial Premium: $154.20
Florida Department of Financial Services Consumer Services Division: 877-693-5236 (toll-free)
850-413-3089 (out of state callers)
Init 1 Term Initial Annual Effective Expiration
Descriptio iod Premium* Date Date
Term Life Insurance 10 Years** $1,752.30*** 02/11/2020 o2/t 112046
Additional Benefits Provided by Endorsement or Rider:
Benefit 1 Annual Effective Expiratio
Descriptio: Amount Premium Date Date
Accelerated Death Benefit Endorsement N/A N/A “02/11/2020 02/11/2046
Total Annual Premium: $1,752.30
Alternative Modal Premium Options:
Monthly Monthly
Credit Card or EFT Direct Bill* Quarterly Semi-Annual Annual.
Premium: $154.20 $15 0 $455.60 $911:20 $1,752.30
* 10% AAA membership discount applied.
** Coverage is renewable annually thereafter, but not beyond the Expiration Date.
*** Includes $54.00 annual Policy fee.
** An administrative fee of $3.00/month will be added for monthly direct bill.
Conversion Period: To the earliest of the end ofthe Initial Term Period or the Policy Anniversary after the
Insured’s 65" birthday. Minimum one (1) year conversion period.
Address and phone number for Premium payment, inquiries and notification of claim:
AAA Life Insurance Company
17900 N. Laurel Park Drive
Livonia, Ml 48152
1-800-624-1662
Date Printed: 02/26/2020
1801(FL)
NEW POLICY @/A
ay”
4042532939 sone
17900 N. Laurel Park Dr.
Life insurance Application for Individual Life Insurance Livonia, MI 48152
Conipany Part 2 (800) 624-1662
= ar
fs ee
Full Legal Nam Social Security Number
THU T NGUYEN
State/Country of Birth: U.S. Citizen Permanent Resident
VIETNAM
@ Yes O No @ Yes CI No
Visa Type: Visa Number: Alien Registration (Green Card) Number: Expiration Date of Visa/Green Card:
Ol
Employer Name: Employer Address:
Is this business coverage? If applicable, list Partners’ Are you employed by the Armed Forces or are you
O Yes & No Total Insurance Coverag amember of the Reserves? (J Yes KJ No
pd, 334
sips
Spouse’s/Parent’s Annual Incom: Total Life Insurance Coverage on Spouse/Pare!
ems
joesFather hi
best of your knowledge and eli? QYes (No CUN/A Total Coverage:
Does Mother have Life Insurance to the
best of your knowledge and belief? Oyves No O1N/A Total Coverage:
Do All Siblings have Life Insurance to the
bestof your knowledge at lief? OyYes QNo CNA Total Coverage for Each Sibling:
oe es
Primary Care Physician Name, Address and Phone Number:
IDR. SUNDEEP SHAH; 352-259-2159; 1580 SANTA BARBARA BLVD; THE VILLAGES, FL 32162
Height: Weight:
ft in 135 bg In the last-12 months, have you lost more than 20 pounds? OYes Ml No fQMWA
4. Have you been fcfo a doctor or r medical faci, or consulted a Heneed medical professional in the last 6 months? Byes ON N/A
ETE
[eve dou ye jedica) professionalta
Heart or Vascular Disorder, chest paln, circulatory isorder, high blood. pressure, or elevated lipids (cholesterol or ClYes No /QWA
triglycerides)?
Stroke, Transient Ischemic Attack (TIA or mini-stroke), migraines or seizure? OyYes & No QNA:
Diabetes, thyroid disorder, pancreatic disorder, liver disorder, hepatitis or kidney disorder? Cyes @ No Ona:
Lung or chronic respiratory disorder, sleep apnea or asthma? OyYes 4 No QNA:
Cancer, tumor, cyst or growth? Clyes 2 No rONA
Rheumatoid Arthritis, Lupus, Multiple Sclerosis, Other autoimmune or connective tissue disorder (excluding AIDS
and HIV)? Ores KI No; OMA
Hae
you ever i=. 8 ue
8. Tested positive for exposure to the Human Immunodeficiency Virus (HIV) Infection or been di nosed ass having OYes
X1 No {CUN/A:
AIDS caused by the HIV Infection or other sickness or condition derived from such infection?
9. Had a parent or sibling diagnosed or treated by a licensed medical professional for heart disease, cancer, Polycystic Oyes & No QNa
Kidney Disease or Huntington's Disease to the best of your knowledge and belief?
10, Been denied coverage or rated an extra premium for life insurance? O Yes dl No OQ NA}
11. Been arrested, charged, or convicted of a felony or misdemeanor other than a traffic violation? OlyYes Bl No ONA:
12. Used any illicit drugs not prescribed by a physician, or have been advised by aicensed medical professional to, or OYes Mf No QUA:
received treatment or counseling for drug or alcohol use?
13. Used any tobacco or nicotine product in any form, chewing tobacco, cigars, e-cigs, hookahs or pipes? O Yes KlNo fON/A
LF80302APP-FL Page 1 ALAN-22794-715-FL
A5194845 rear moreno
OLD MRR POLICY STATEMENT
AAA LIFE INSURANCE COMPANY
17900 N. Laurel Park Drive, Livonia, MI 48152-3985
(800) 624-1662
Agent’s Name and Address:
CALIFORNIA STATE AUTO ASSOC
150 VAN NESS AVENUE
SAN FRANCISCO, CA 94102-5279
STATEMENT OF POLICY COST AND BENEFIT INFORMATION
Prepared on: July 11, 2013
Insured: THU T NGUYEN
Benefit Description Specified Amount Expiry Date Annual Premium
Term Life Insurance $100,000 7/11/2045 $1,427.50
Benefit Description Benefit Amount Expiry Date Annual Premium
Accelerated Death Benefit Endorsement N/A 7/11/2045 N/A
Lifetime Membership Benefit Endorsement N/A 7/11/2045 N/A
Policy Number: 4022724274 Issue Age: 63
Effective Date: 07/11/2013 Gender: Male
Billing Frequency: Monthly Modal Premium: $125.62
Conversion Period: To the earliest of the Initial Term Period or the Policy Anniversary after the Insured’s 65"
Birthday. No conversions will be allowed after Attained Age 65.
Plan of Insurance: Term Life Insurance Policy to Age 95. Level Premium Term Life Insurance through the Level
Premium Period, thereafter Annual Renewable Term Life Insurance to the Policy Anniversary after the Insured’s 95"
birthday.
NOTE: DO NOT CONSIDER ANY VERBAL REPRESENTATION MADE BY THE AGENT UNLESS IT IS DISCLOSED
IN WRITING IN A FORM SIGNED BY THE AGENT, AND THE AGENT LEAVES THE WRITTEN DISCLOSURE WITH
YOU.
For further information, contact your agent, or write to the Company at the mailing address listed on the top of
this page.
Page 1
OLD POLICY SCHEpuLE
» Insured: THU T NGUYEN Policy Number: 4022724274
Schedule of Policy Premiums and Additional Benefits Provided by Rider
Term Life Insurance to Age 95
Policy Base Annual Maximum Annual Benefit
Year Premium Premium Amount
$1,427.50 $1,427.50 $100,000
$1,427.50 $1,427.50 $100,000
$1,427.50 $1,427.50 $100,000
$1,427.50 $1,427.50 $100,000
$1,427.50 $1,427.50 $100,000
$1,427.50 $1,427.50 $100,000
$1,427.50 $1,427.50 $100,000
$1,427.50 $1,427.50 $100,000
$1,427.50 $1,427.50 $100,000
10 $1,427.50 $1,427.50 $100,000
11 $8,085.50 $8,085.50 $100,000
12 $9,197.50 $9,197.50 $100,000
13 $10,445.50 $10,445.50 $100,000
14 $11,839.50 $11,839.50 $100,000
15 $13,475.50 $13,475.50 $100,000
16 $18,659.50 $18,659.50 $100,000
17 $25,133.50 $25,133.50 $100,000
18 $33,003.50 $33,003.50 $100,000
19 $41,641.50 $41,641.50 $100,000
20 $51,483.50 $51,483.50 $100,000
25 $100,000.00 $100,000.00 $100,000
30 $100,000.00 $100,000.00 $100,000
65 $1,427.50 $1,427.50 $100,000
LIFE INSURANCE COST INDICES PER $1,000 OF DEATH BENEFIT
5 Year 10 YEAR 20 YEAR
Net Payment Index 14.28 14.27 86.65
Indices are based on the payment of the annual premiums during the stated period.
An explanation of the intended use of these indices is provided in the Life Insurance Buyer’s Guide. Indices are useful
only for the comparison of the relative costs of two or more similar policies.
Page 2
.
. OLD POLICY OIA 4022724274
eon
7
Compaiy
Application for individual Life Insurance
Part 2
17900 N. Laurel Park Dr.
Livonia, MI 48152
(800) 624-4 662
Full Legal Name Social Secu Number
[THU T NGUYEN I586-40-0999
State/Country of Birth USS. Citizen - Permanent Resident
VIETNAM ElYes ONo BYes 01 No
Visa Type Visa Number Alien Registration (Green Card) Number Expiration Date of Visa/Green Card
OR
Employer Name Employer Address
IG4S SECURE SOLUTIONS 100 CENTURY CENTER CT STE 200; SAN JOSE, CA
Is this business coverage? ||f applicable, list Partners’ Are you employed by the Armed Forces or are you a
OYes & No Total Insurance Coverage: member of the Reserves? £1 Yes KI No
18 1218) } para i a3 Aisiilsiod| eral rare Fs 8)
iSpouse's/Parent's Annual Income Total Life Insurance Coverage on Spouse/Parent
$ $
eG} ae JERSESy, i 8)
Does Father Have Life Insurance? O Yes C1 No CNAA Total Coverage
Does Mother Have Life Insurance? OYes C1No N/A Total Coverage
Do All Siblings Have Life Insurance? OYes ONo O NA Total Coverage for Each Sibling
Primary Care Physician Name, Address, and Phone Number
KAISER PERMANENTE; 000-000-0000; UNKNOWN ADDRESSKAISER ID 06633950; MILPITAS, cA.
Height Weight In the last 12 months, have you lost more than 20 pounds? O Yes EI No ONA
5ft 3 in 150 lbs
Have you, ever | been diagnosed, treated, or advised to seek treatment by a memberof the medical
profession for:
4 Heart disorder, including chest pain, oaulatory disorder, high blood pressure, or elevated lipids (cholesterol or @ Yes ONo ONA
triglycerides)?
Stroke, Transient Ischemic Attack (TIA or mini-stroke), or seizure? O Yes KI No ONA
Diabetes, thyroid disorder, pancreatic disorder, liver disorder including, but not limited to, hepatitis, or kidney
O Yes KINo a NIA
disorder?
Lung or chronic respiratory disorder including, but not limited to, sleep apnea or asthma? O Yes KINo ONA
Cancer or tumor, cyst, or growth? O Yes No ONA
6 Rheumatoid Arthritis, Lupus, Multiple Sclerosis, or other autoimmune or connective tissue disorder? Yes No ONA
7. . Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)? O Yes No ONA
Have you ever:
8, Had a parent or sibling diagnosed or treated by a member of the medical profession for heart disease, :
0 Yes No ONA
cancer, or diabetes?
19. Had a parent or sibling diagnosed or treated by a member of the medical profession for Polycystic Kidney
D Yes EINo ONA
disease or Huntington's disease?
10. Been denied coverage or rated an extra premium for life insurance? OYes No ONA
11. Been arrested, charged, or convicted of a felony or misdemeanor other than a traffic violation? Yes No ONA
LF80202APPr CA Page 1 of 3 ALAN-19601-411-CA
66401220 marr om oxrerryear
T N DANG POLICY
AAA LIFE INSURANCE COMPANY
17900 N. Laurel Park Drive, Livonia, Ml 48152-3985
(800) 624-1662
Agent’s Name and Address:
CALIFORNIA STATE AUTO ASSOC
150 VAN NESS AVENUE
SAN FRANCISCO, CA 94102-5279
STATEMENT OF POLICY COST AND BENEFIT INFORMATION
Prepared on: June 9, 2013
Insured: TIEN DANG
Benefit Description Specified Amount Expiry Date Annual Premium
Term Life Insurance $100,000 6/7/2070 $95.50
Benefit Description Benefit Amount Expiry Date Annual Premium
Accelerated Death Benefit Endorsement N/A 6/7/2070 N/A
Lifetime Membership Benefit Endorsement N/A 6/7/2070 N/A
Policy Number: 4022724290 Issue Age: 38
Effective Date: 06/07/2013 Gender: Female
Billing Frequency: Monthly Modal Premium: $8.40
Conversion Period: To the earliest of the Initial Term Period or the Policy Anniversary after the Insured’s 65
Birthday. No conversions will be allowed after Attained Age 65.
Plan of Insurance: Term Life Insurance Policy to Age 95. Level Premium Term Life Insurance through the Level
Premium Period, thereafter Annual Renewable Term Life Insurance to the Policy Anniversary after the Insured’s 95t
birthday.
NOTE: DO NOT CONSIDER ANY VERBAL REPRESENTATION MADE BY THE AGENT UNLESS IT IS DISCLOSED
IN WRITING IN A FORM SIGNED BY THE AGENT, AND THE AGENT LEAVES THE WRITTEN DISCLOSURE WITH
YOU.
For further information, contact your agent, or write to the Company at the mailing address listed on the top of
this page.
Page 1
TIEN DANG POLICY SCHEDULE
a Insured: TIEN DANG Policy Number: 4022724290
oe -
Schedule of Policy Premiums and Additional Benefits Provided by Rider
Term Life Insurance to Age 95
Policy Base Annual Maximum Annual Benefit
Year Premium Premium Amount
$95.50 $95.50 $100,000
$95.50 $95.50 $100,000
$95.50 $95.50 $100,000
$95.50 $95.50 $100,000
$95.50 $95.50 $100,000
$95.50 $95.50 $100,000
$95.50 $95.50 $100,000
$95.50 $95.50 $100,000
$95.50 $95.50 $100,000
10 $95.50 $95.50 $100,000
11 $95.50 $95.50 $100,000
12 $95.50 $95.50 $100,000
13 $95.50 $95.50 $100,000
14 $95.50 $95.50 $100,000
15 $95.50 $95.50 $100,000
16 $95.50 $95.50 $100,000
17 $95.50 $95.50 $100,000
18 $95.50 $95.50 $100,000
19 $95.50 $95.50 $100,000
20 $95.50 $95.50 $100,000
25 $766.50 $766.50 $100,000
30 $2,412.50 $2,412.50 $100,000
Preview
COMPLAINT in the DISTRICT Court for the County of LAKE in the State of FLORIDA Case Number: Date: December 21, 2022 GENERAL INFORMATION IDCAIDSY PLAINTIFF Ms. Tien T Dang 5356 Treasure View Way, Leesburg FL. 34748 DEFENDANT: Mr. Margo Jenkins AAA Life Insurance Company 17900 N. Laurel Park Drive, Livonia, MI. 48152 RE: AAA Life Insurance Claim Number: 2100013682 New policy number issued February 26,2020:# 4042532939 Old policy number issued in July 2013: #4022724274 Insured: Mr. Thu Nguyen Date of Loss: 08/29/2021 Jur{ Tial Deaneef’ DESCRIPTION OF COMPLAINT: 1. Mr. Thu Nguyen applied and got approved for $100,000 of Group Term Life Insurance in 2013 from AAA in San Jose, California. The insurance number 4022724274 was put into effect and signed by Mr. Harold W. Huffstetler, Jr. The approval letter stated that “Once in effect, you can renew it through the age of 79 regardless of any changes in your health.” The monthly premium was $125.62 and kept unchanged from year 1 to year 10. The policy won’t be expired until 7/11/2045. The premiums were deducted automatically monthly through our checking account at the Bank of America. 2. At the same time, to counterpart with his decision, I also applied for a term life insurance in San Jose, California, and got approved for the same amount $100,000. The policy number is 4022724290 and the premium was $$8.40 automatically deducted through the same Bank of America. 3. We moved to Florida in 2018. On 02/26/2020, AAA issued a new 10 years Term life insurance policy to Mr. Thu Nguyen and the number is 4042532939. The monthly premium was increased from $125.62 to $154.20. What were the reasons behind that AAA replacing a new policy while the 100K amount and other terms were unchanged? Who was the party, AAA or Mr. Thu Nguyen, who initiated the ® request? Does AAA still have all the evidence, letter, and/or audio conversation at the time of the policy replacement? 4. Mr. Thu Nguyen passed away on August 29, 2021, from COVID-19. I submitted the claim with AAA in September 2021 as the survival benefit. AAA issued claim'# 2100013682. 5. As his wife, I did not recall why Mr. Thu Nguyen requested a new policy. The premiums should be unchanged after 10 years as stated per the old policy. I did not know-he had a new policy when I claimed the 100K after his death on August 29, 2021, as part of the survival benefit. In March 2022, I stopped at one local AAA office in Lady Lake and met ‘with Mr. Alex Hanson, the AAA financial specialist.He told us the reason the claim was delayed because of the new contract issued less than 2 years from the date issued date Feb 26, 2020. I reviewed my own AAA policy at that time and it was . the same monthly amount of $8.40. The policy number was unchanged # 4022724290. 6. As part of the claim investigation, AAA concluded that Mr. Thu Nguyen’s No answer to application question 4 was a misrepresentation. The medical records demonstrated that he was diagnosed with Hepatitis B prior to the Application date of 02/26/2020. Therefor re AAA exercised its right to deny the 100K coverage. . 7. Does AAA still have the evidence, written and or audio conversation during the new application process of the answer question 4? The answer No to this question was in both old and new policies. Mr. Thu Nguyen got treatment from a medical professional after the diagnosis. 8. For question 1 related to heart disorder, high blood pressure, or elevated lipids, the answer is YES for the old policy-and NO for the new one. The reason for the different answers was that he knew he had these sicknesses, so he got treated by a member of the medical profession after the diagnosis. He also turned to a Vegetarian/Vegan diet in 1993 to improve his health and cure these diseases. Damages WHEREFORE, Plaintiff seeks compensatory damages in the amount of $100,000 as stated per the term life insurance policy agreement plus all attorney fées and costs incurred by Plaintiff in connection with this action. Respectfully submitted this 21st day of December 2022. Name: Tien T Dang, Plaintiff adeng _ Company 17900 N. Laurel Park Drive Livonia; Michigan 48152 Phone: 800-624-1662 May 26, 2022 Fax: 888-223-1509 claimssvc@aaalife.com Tien Thi Dang 14055 SE 93rd Ter Summerfield, FL 34491 RE: AAA Life Insurance Claim Number: 2100013682 Contract Number: 4042532939 Insured: Thu T Nguyen Issue Date: 02/26/2020 Date of Loss: 08/29/2021 Dear Tien Thi Dang, Thank you for your patience while we reviewed the submitted. information on this claim. . Please accept our sincere sympathies on your loss. We have had an opportunity to review your April 28, 2022 correspondence in conjunction with the previously reviewed claim documentation. Unfortunately, no additional information was provided that would cause us to change our April 11, 2022 decision fo rescind and void the coverage under policy 4042532939. Briefly, in response to your question regarding why the contract number changed, your: husband Thu Nguyen replaced his coverage with a 10-year’ Term Life policy with an Issue Date of February 26, 2020 and a new contract number 4042532939: The new policy, as you are aware from our April 11, 2022 letter, had a two-year contestability period from the contract Issue date. Your husband’s death occurred during that two-year period. As the death occurred within the two years, during the contestable period, there was a.claim . investigation. The claim investigation concluded that Thu Nguyen’s No” answer to.Application Part 2, question four (4) was a misrepresentation. The medical records demonstrated that Mr. Nguyen was diagnosed with Hepatitis B prior to the Application date. Mr. Nguyen was followed by the liver specialist for this disease. The question did not ask about his current treatment status with the condition but rather “Have you ever been diagnosed, treated, or consulted a licensed medical professional for: 4. Diabetes, thyroid disorder, pancreai tic disorder, liver disorder, hepatitis or kidney disorder?” As you know, Mr. Thu Nguyen answered “No” to this question. Page 3 of 3 | hope this fully explains how this determination has been reached. If you have questions tegarding this mat ter, Please contact our office at 1-800-624-1662, and follow the prompts. for Claims." We appreciate the opportunity to respond, and am sorry we are unable to honor the request for benefits. Sincerely, Greg Thomsow Greg Thomson Claim Consultant, Claims Department a ~— 4+7900°N- Laurel Park Dr: Livonia, MI48152-— Direct: 734-779-2927 | 800-624-1662 Ext. 2927 — ee —— = ee — ae -. pets ears << oh PS ti Ea me am a POE im Policy# ISTi , ae 404253 2939 a AT on iHO! DEATH INE IBER=/20; EPTEN Disaster #4486 aa aa Heth oe Me Regi strcition # 413419384 RTH: a iy Sane i,(ON REET S eu AD;SI ER OC CE. a SE83 ft a IGHES ore UAT ‘DFO i Fax # UR EPA ri 855261 3452 AM \PPI rh a he ae Be CLAIM A Cl 2 ie INE QlOool 2437 is Cl) Ace ae 1 oe < ORESesve va =DAN( ot & er oe a 5 ar SirAsi TAG ee ae EN (oh RUA SIT ‘Orit Ss. Be iF Nee EDI BEA SenTAI peut OF Pi IED: 20: FEI Ean ice NS BER: ace ae bit STITION LIC, OF eo 101 5 ae Eel re se ee ae fut ‘OKI Oo” Et BOXIC! ae NA et me Ue ieee ge iSIGNIFI 101 i uch 5, iN ae ee ist ae ee GER) ERS 28 ‘DIDS ey e IE Fe ia INgt fete: cA ‘DESCRIE NF: INJURYOCCURE IP TE ae rss ee e sie EN ree Be SPF ae mea AE eA sesh aie ER mere "rie cs cre TE® can a TICOLORED. ealbgah av i il a i il Pye ia og oy ee Maser wes KX AeaS ee aD BLARFZ & NEW POLICY # 4042532939 Policy Schedule Page Policy Number: 4042532939 Effective Date: 02/41/2020 Owner: THU T NGUYEN Issue Date: 02/26/2020 Insured: THU T NGUYEN Issue State: FL Issue Age: 69 Gender: Male Face Amount: | $100,000 Rate Class: STANDARD NON- NICOTINE Billing Mode: Monthly EFT Initial Premium: $154.20 Florida Department of Financial Services Consumer Services Division: 877-693-5236 (toll-free) 850-413-3089 (out of state callers) Init 1 Term Initial Annual Effective Expiration Descriptio iod Premium* Date Date Term Life Insurance 10 Years** $1,752.30*** 02/11/2020 o2/t 112046 Additional Benefits Provided by Endorsement or Rider: Benefit 1 Annual Effective Expiratio Descriptio: Amount Premium Date Date Accelerated Death Benefit Endorsement N/A N/A “02/11/2020 02/11/2046 Total Annual Premium: $1,752.30 Alternative Modal Premium Options: Monthly Monthly Credit Card or EFT Direct Bill* Quarterly Semi-Annual Annual. Premium: $154.20 $15 0 $455.60 $911:20 $1,752.30 * 10% AAA membership discount applied. ** Coverage is renewable annually thereafter, but not beyond the Expiration Date. *** Includes $54.00 annual Policy fee. ** An administrative fee of $3.00/month will be added for monthly direct bill. Conversion Period: To the earliest of the end ofthe Initial Term Period or the Policy Anniversary after the Insured’s 65" birthday. Minimum one (1) year conversion period. Address and phone number for Premium payment, inquiries and notification of claim: AAA Life Insurance Company 17900 N. Laurel Park Drive Livonia, Ml 48152 1-800-624-1662 Date Printed: 02/26/2020 1801(FL) NEW POLICY @/A ay” 4042532939 sone 17900 N. Laurel Park Dr. Life insurance Application for Individual Life Insurance Livonia, MI 48152 Conipany Part 2 (800) 624-1662 = ar fs ee Full Legal Nam Social Security Number THU T NGUYEN State/Country of Birth: U.S. Citizen Permanent Resident VIETNAM @ Yes O No @ Yes CI No Visa Type: Visa Number: Alien Registration (Green Card) Number: Expiration Date of Visa/Green Card: Ol Employer Name: Employer Address: Is this business coverage? If applicable, list Partners’ Are you employed by the Armed Forces or are you O Yes & No Total Insurance Coverag amember of the Reserves? (J Yes KJ No pd, 334 sips Spouse’s/Parent’s Annual Incom: Total Life Insurance Coverage on Spouse/Pare! ems joesFather hi best of your knowledge and eli? QYes (No CUN/A Total Coverage: Does Mother have Life Insurance to the best of your knowledge and belief? Oyves No O1N/A Total Coverage: Do All Siblings have Life Insurance to the bestof your knowledge at lief? OyYes QNo CNA Total Coverage for Each Sibling: oe es Primary Care Physician Name, Address and Phone Number: IDR. SUNDEEP SHAH; 352-259-2159; 1580 SANTA BARBARA BLVD; THE VILLAGES, FL 32162 Height: Weight: ft in 135 bg In the last-12 months, have you lost more than 20 pounds? OYes Ml No fQMWA 4. Have you been fcfo a doctor or r medical faci, or consulted a Heneed medical professional in the last 6 months? Byes ON N/A ETE [eve dou ye jedica) professionalta Heart or Vascular Disorder, chest paln, circulatory isorder, high blood. pressure, or elevated lipids (cholesterol or ClYes No /QWA triglycerides)? Stroke, Transient Ischemic Attack (TIA or mini-stroke), migraines or seizure? OyYes & No QNA: Diabetes, thyroid disorder, pancreatic disorder, liver disorder, hepatitis or kidney disorder? Cyes @ No Ona: Lung or chronic respiratory disorder, sleep apnea or asthma? OyYes 4 No QNA: Cancer, tumor, cyst or growth? Clyes 2 No rONA Rheumatoid Arthritis, Lupus, Multiple Sclerosis, Other autoimmune or connective tissue disorder (excluding AIDS and HIV)? Ores KI No; OMA Hae you ever i=. 8 ue 8. Tested positive for exposure to the Human Immunodeficiency Virus (HIV) Infection or been di nosed ass having OYes X1 No {CUN/A: AIDS caused by the HIV Infection or other sickness or condition derived from such infection? 9. Had a parent or sibling diagnosed or treated by a licensed medical professional for heart disease, cancer, Polycystic Oyes & No QNa Kidney Disease or Huntington's Disease to the best of your knowledge and belief? 10, Been denied coverage or rated an extra premium for life insurance? O Yes dl No OQ NA} 11. Been arrested, charged, or convicted of a felony or misdemeanor other than a traffic violation? OlyYes Bl No ONA: 12. Used any illicit drugs not prescribed by a physician, or have been advised by aicensed medical professional to, or OYes Mf No QUA: received treatment or counseling for drug or alcohol use? 13. Used any tobacco or nicotine product in any form, chewing tobacco, cigars, e-cigs, hookahs or pipes? O Yes KlNo fON/A LF80302APP-FL Page 1 ALAN-22794-715-FL A5194845 rear moreno OLD MRR POLICY STATEMENT AAA LIFE INSURANCE COMPANY 17900 N. Laurel Park Drive, Livonia, MI 48152-3985 (800) 624-1662 Agent’s Name and Address: CALIFORNIA STATE AUTO ASSOC 150 VAN NESS AVENUE SAN FRANCISCO, CA 94102-5279 STATEMENT OF POLICY COST AND BENEFIT INFORMATION Prepared on: July 11, 2013 Insured: THU T NGUYEN Benefit Description Specified Amount Expiry Date Annual Premium Term Life Insurance $100,000 7/11/2045 $1,427.50 Benefit Description Benefit Amount Expiry Date Annual Premium Accelerated Death Benefit Endorsement N/A 7/11/2045 N/A Lifetime Membership Benefit Endorsement N/A 7/11/2045 N/A Policy Number: 4022724274 Issue Age: 63 Effective Date: 07/11/2013 Gender: Male Billing Frequency: Monthly Modal Premium: $125.62 Conversion Period: To the earliest of the Initial Term Period or the Policy Anniversary after the Insured’s 65" Birthday. No conversions will be allowed after Attained Age 65. Plan of Insurance: Term Life Insurance Policy to Age 95. Level Premium Term Life Insurance through the Level Premium Period, thereafter Annual Renewable Term Life Insurance to the Policy Anniversary after the Insured’s 95" birthday. NOTE: DO NOT CONSIDER ANY VERBAL REPRESENTATION MADE BY THE AGENT UNLESS IT IS DISCLOSED IN WRITING IN A FORM SIGNED BY THE AGENT, AND THE AGENT LEAVES THE WRITTEN DISCLOSURE WITH YOU. For further information, contact your agent, or write to the Company at the mailing address listed on the top of this page. Page 1 OLD POLICY SCHEpuLE » Insured: THU T NGUYEN Policy Number: 4022724274 Schedule of Policy Premiums and Additional Benefits Provided by Rider Term Life Insurance to Age 95 Policy Base Annual Maximum Annual Benefit Year Premium Premium Amount $1,427.50 $1,427.50 $100,000 $1,427.50 $1,427.50 $100,000 $1,427.50 $1,427.50 $100,000 $1,427.50 $1,427.50 $100,000 $1,427.50 $1,427.50 $100,000 $1,427.50 $1,427.50 $100,000 $1,427.50 $1,427.50 $100,000 $1,427.50 $1,427.50 $100,000 $1,427.50 $1,427.50 $100,000 10 $1,427.50 $1,427.50 $100,000 11 $8,085.50 $8,085.50 $100,000 12 $9,197.50 $9,197.50 $100,000 13 $10,445.50 $10,445.50 $100,000 14 $11,839.50 $11,839.50 $100,000 15 $13,475.50 $13,475.50 $100,000 16 $18,659.50 $18,659.50 $100,000 17 $25,133.50 $25,133.50 $100,000 18 $33,003.50 $33,003.50 $100,000 19 $41,641.50 $41,641.50 $100,000 20 $51,483.50 $51,483.50 $100,000 25 $100,000.00 $100,000.00 $100,000 30 $100,000.00 $100,000.00 $100,000 65 $1,427.50 $1,427.50 $100,000 LIFE INSURANCE COST INDICES PER $1,000 OF DEATH BENEFIT 5 Year 10 YEAR 20 YEAR Net Payment Index 14.28 14.27 86.65 Indices are based on the payment of the annual premiums during the stated period. An explanation of the intended use of these indices is provided in the Life Insurance Buyer’s Guide. Indices are useful only for the comparison of the relative costs of two or more similar policies. Page 2 . . OLD POLICY OIA 4022724274 eon 7 Compaiy Application for individual Life Insurance Part 2 17900 N. Laurel Park Dr. Livonia, MI 48152 (800) 624-4 662 Full Legal Name Social Secu Number [THU T NGUYEN I586-40-0999 State/Country of Birth USS. Citizen - Permanent Resident VIETNAM ElYes ONo BYes 01 No Visa Type Visa Number Alien Registration (Green Card) Number Expiration Date of Visa/Green Card OR Employer Name Employer Address IG4S SECURE SOLUTIONS 100 CENTURY CENTER CT STE 200; SAN JOSE, CA Is this business coverage? ||f applicable, list Partners’ Are you employed by the Armed Forces or are you a OYes & No Total Insurance Coverage: member of the Reserves? £1 Yes KI No 18 1218) } para i a3 Aisiilsiod| eral rare Fs 8) iSpouse's/Parent's Annual Income Total Life Insurance Coverage on Spouse/Parent $ $ eG} ae JERSESy, i 8) Does Father Have Life Insurance? O Yes C1 No CNAA Total Coverage Does Mother Have Life Insurance? OYes C1No N/A Total Coverage Do All Siblings Have Life Insurance? OYes ONo O NA Total Coverage for Each Sibling Primary Care Physician Name, Address, and Phone Number KAISER PERMANENTE; 000-000-0000; UNKNOWN ADDRESSKAISER ID 06633950; MILPITAS, cA. Height Weight In the last 12 months, have you lost more than 20 pounds? O Yes EI No ONA 5ft 3 in 150 lbs Have you, ever | been diagnosed, treated, or advised to seek treatment by a memberof the medical profession for: 4 Heart disorder, including chest pain, oaulatory disorder, high blood pressure, or elevated lipids (cholesterol or @ Yes ONo ONA triglycerides)? Stroke, Transient Ischemic Attack (TIA or mini-stroke), or seizure? O Yes KI No ONA Diabetes, thyroid disorder, pancreatic disorder, liver disorder including, but not limited to, hepatitis, or kidney O Yes KINo a NIA disorder? Lung or chronic respiratory disorder including, but not limited to, sleep apnea or asthma? O Yes KINo ONA Cancer or tumor, cyst, or growth? O Yes No ONA 6 Rheumatoid Arthritis, Lupus, Multiple Sclerosis, or other autoimmune or connective tissue disorder? Yes No ONA 7. . Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)? O Yes No ONA Have you ever: 8, Had a parent or sibling diagnosed or treated by a member of the medical profession for heart disease, : 0 Yes No ONA cancer, or diabetes? 19. Had a parent or sibling diagnosed or treated by a member of the medical profession for Polycystic Kidney D Yes EINo ONA disease or Huntington's disease? 10. Been denied coverage or rated an extra premium for life insurance? OYes No ONA 11. Been arrested, charged, or convicted of a felony or misdemeanor other than a traffic violation? Yes No ONA LF80202APPr CA Page 1 of 3 ALAN-19601-411-CA 66401220 marr om oxrerryear T N DANG POLICY AAA LIFE INSURANCE COMPANY 17900 N. Laurel Park Drive, Livonia, Ml 48152-3985 (800) 624-1662 Agent’s Name and Address: CALIFORNIA STATE AUTO ASSOC 150 VAN NESS AVENUE SAN FRANCISCO, CA 94102-5279 STATEMENT OF POLICY COST AND BENEFIT INFORMATION Prepared on: June 9, 2013 Insured: TIEN DANG Benefit Description Specified Amount Expiry Date Annual Premium Term Life Insurance $100,000 6/7/2070 $95.50 Benefit Description Benefit Amount Expiry Date Annual Premium Accelerated Death Benefit Endorsement N/A 6/7/2070 N/A Lifetime Membership Benefit Endorsement N/A 6/7/2070 N/A Policy Number: 4022724290 Issue Age: 38 Effective Date: 06/07/2013 Gender: Female Billing Frequency: Monthly Modal Premium: $8.40 Conversion Period: To the earliest of the Initial Term Period or the Policy Anniversary after the Insured’s 65 Birthday. No conversions will be allowed after Attained Age 65. Plan of Insurance: Term Life Insurance Policy to Age 95. Level Premium Term Life Insurance through the Level Premium Period, thereafter Annual Renewable Term Life Insurance to the Policy Anniversary after the Insured’s 95t birthday. NOTE: DO NOT CONSIDER ANY VERBAL REPRESENTATION MADE BY THE AGENT UNLESS IT IS DISCLOSED IN WRITING IN A FORM SIGNED BY THE AGENT, AND THE AGENT LEAVES THE WRITTEN DISCLOSURE WITH YOU. For further information, contact your agent, or write to the Company at the mailing address listed on the top of this page. Page 1 TIEN DANG POLICY SCHEDULE a Insured: TIEN DANG Policy Number: 4022724290 oe - Schedule of Policy Premiums and Additional Benefits Provided by Rider Term Life Insurance to Age 95 Policy Base Annual Maximum Annual Benefit Year Premium Premium Amount $95.50 $95.50 $100,000 $95.50 $95.50 $100,000 $95.50 $95.50 $100,000 $95.50 $95.50 $100,000 $95.50 $95.50 $100,000 $95.50 $95.50 $100,000 $95.50 $95.50 $100,000 $95.50 $95.50 $100,000 $95.50 $95.50 $100,000 10 $95.50 $95.50 $100,000 11 $95.50 $95.50 $100,000 12 $95.50 $95.50 $100,000 13 $95.50 $95.50 $100,000 14 $95.50 $95.50 $100,000 15 $95.50 $95.50 $100,000 16 $95.50 $95.50 $100,000 17 $95.50 $95.50 $100,000 18 $95.50 $95.50 $100,000 19 $95.50 $95.50 $100,000 20 $95.50 $95.50 $100,000 25 $766.50 $766.50 $100,000 30 $2,412.50 $2,412.50 $100,000